| Name | Value |
|---|---|
| PROVIDER TYPE | Nursing Service Providers |
| CLASSIFICATION | Registered Nurse |
| AREA OF SPECIALIZATION | Addiction (Substance Use Disorder) |
| STATUS | Active |
| VA CODE | V070901 |
| X12 CODE | 163WA0400X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5252867 |
| EFFECTIVE DATE/TIME |
|